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THE USE OF NARRATIVE STRATEGIES BASED ON FAIRYTALES AS A NOVEL,INTEGRATIVE INGREDIENT IN CBT: A CASE REPORT

Chiara Ruini, PhD, # and Fedra Ottolini, PhD

Even though cognitive behavioral therapy (CBT) is oftenthe recommended treatment for mental health problems, itmay present limitations when dealing with existential or moral issues. The aim of this case report is to describe theintroduction of narrative techniques based on traditionalfairytales in the process of CBT, in order to overcometreatment resistances and to help the patient in dealing with major life crises. In the case presented, the joint useof these two techniques helped the patient to achieve

the right self-distance from her problems, allowing her toreach a new, wider perspective and a subjective self-maturation.

Key words: Narrative therapy, CBT, fairytales, psychother-apy, treatment resistance

(Explore 2014; 10:121-124 & 2014 Elsevier Inc. All rightsreserved.)

INTRODUCTION The cognitive behavioral group of therapies (CBTs) have

ourished over the last four decades. The CBT approachemphasizes the links between thoughts, feelings, and behav-iors connected with, and responsible for, psychologicaldisorders. CBT is aimed at targeting the maladaptive beliefsand biased information processing that underpin the distress-ing emotions and damaging behaviors associated with speci cpsychological conditions. However, some research 1 ,2 haspointed to several pr oblems in the application of CBT. For instance, Goldfried 1 ,2 noted that CBT fails in several areas.First, even if CBT provides a micro-analysis of reactions tospeci c problematic situations, it usually prevents an explora-tion of the big picture. Second, because CBT is based onskills-training orientation, the therapist is most effective if heor she serves as more a didactic teacher than as a healer. 3 ,4

Further, although CBT has provided effective interventionsfor reducing symptomatology, a comprehensive view of theself is often lacking, leaving CBT at times not able to addressthe recent call for more attention to humanism in psycho-therapeutic settings. 5 ,6

The need to integrate these rigid protocols of CBT with amore holistic approach has recently been addressed by the third-wave psychotherapies, which basically combine CBTtechniques with mindfulness strategies and meditation tech-niques, guided by some c on cepts taken from Eastern philos-ophy, such as acceptance. 7 ,8 The need for a more humanistic

and holistic consideration of p atients also dovetails with the narrative medicine framework,6 ,9

12 which calls for a holisticapproach to the patient, involving not only his/her illness,but his/her b iogr aphy, narrative, and cognitive interpretationof the illness.9

12

White and Epston 13 observed that individual narrativesassociated with psychological distress were often characterizedby thin and impoverished stories. They developed a narrativetherapy 13 with the aims of deconstructing dominant problemstories, incorporating previously neglected stories into theoverall life story of the person, and achieving nal enrichedlife stories. The use of narrative strategies in clinical psy-chol og y and psychotherapy has a long tradition. 14 Following Jung 15 and his theories on archetypes and myths, Jungianpsychoanalysts have applied t hese concepts in the treatmentof various emotional disorders. 16 Many contemporary authorsunderline the clinical value of employing myths andmetaphors in cluded in various f airytales in the process of psychotherapy 17 ; Bettelheim s18 ,19 analytic interpretations of fairytales is one of the best known of these approaches. Someclinicians in the psychoanalytic setting use traditional fairy-tales and their protagonists (hero/heroine) with the ir patientsin order to discuss with them their symbolic value. 20

In traditional societies, fairytales have always played animportant psycho-educational role, providing ad hoc frame-works to interpret reality, to deal with personal issues andstressful events, to encourage or warn in facing life s adver-sities, and to help enter adulthood. Fairytales were aimed atyoung adults more than children, and storytellers were mostly older and well-respected members of the community whocommunicated their wisdo m and life experience through thestories in their repertoires. 4 Their content often deals withseveral concepts that are now scienti cally investigated by clinical psychology and psychotherapy research, including e-mail: chiara.ruini@unibo.it

Department of Psychology, University of Bologna, Viale Berti Pichat5, Bologna 40127, Italy

# Corresponding author .

121& 2014 Elsevier Inc. All rights reserved. EXPLORE March/April 2014, Vol. 10, No. 2ISSN 1550-8307/$36.00 http://dx.doi.org/10.1016/j.explore.2013.12.003

CASE REPORT

mailto:chiara.ruini@unibo.ithttp://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.explore.2013.12.003http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.explore.2013.12.003http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.explore.2013.12.003http://localhost/var/www/apps/conversion/tmp/scratch_5/dx.doi.org/10.1016/j.explore.2013.12.003mailto:chiara.ruini@unibo.it

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resilience, self-realizatio n, personal growth, forgiveness, andmeaning in life. 3 ,4 ,21 ,22 Recently, a pilot study that used anarrative intervention based on fairytales, told and discussedin a group format, yielded promising results with emotionally distressed women. 23 In this preliminary group intervention,21 women with adjustment disorders underwent a seven-session intervention conducted by a folklorist and by a

clinical psychologist. Sessions were each two hours long. Ineach of the rst ve sessions ( lectures ) a different fairytale(or part of it), with related topics (such as the ability to copewith adversities and stressful situations, the use of inner resources and personal strengths, and couple and family dynamics), was told and then discussed with the participants.In the two nal sessions ( workshops ), the women were askedto write as a group their original fairytale, using a narrativebasic structure (based on the conce pt of functions devel-oped in fairytale structuralist analysis 24 ) and consisting of six main phases: initial stressful event, test, tasks, help, ght,victory, and nal reward. The therapist underlined similaritieswith real-life problems, speci c coping strategies adopted by the hero/heroine of the story, and his/her emotional matura-tion, and these themes were discussed by the group.

The aim of this article is to describe the introduction of narrative techniques based on traditional fairytales in theprocess of CBT. Following the previously cited narrativeinterventions, the authors decided to introduce this novelingredient in a standard CBT protocol in order to overcomeresistance to change and dif culties encountered during treatment by a patient with anxiety disorder. The patientprovided written informed consent to have her therapeuticexperience published.

CASE REPORT S. was a 31-year-old woman, who worked as blue collar worker in a textile factory and had gone to live with her boyfriend a year earlier. Since that time, she had beensuffering from panic disorder and agoraphobia, according toDiagnostic and Statistical Manual of Mental Disorders FourthEdition (DSM-IV) criteria. The panic attacks were quitefrequent (on average two per week) and associated withagoraphobic situations, such as traveling, going to super-markets, and going to cinema and restaurants. They were alsolinked to gastroenterologic symptoms (nausea, stomach-ache,and dizziness). S. sought a psychotherapeutic intervention inorder to have her panic disorder treated. A CBT program,based on gradual exposure to feared situations, was carriedout with the patient. She was instructed to keep a diary withautomatic thoughts, error identi cations, and cognitiverestructuring. After six months of treatment, the panic attackshad disappeared and she began to feel much better. At thisstage of the therapy, the therapist started to investigate other problematic areas in the patient s life, and S. reported somedif culties with her boyfriend. In her workplace she was being courted by one of her male colleagues, with whom she had anaffair some years before. She felt she was still attracted to thisother man, but also felt extremely guilty when thinking abouther boyfriend. Additionally, in the same period, a strong

earthquake happened while she was at work. No one wasinjured during the earthquake, but S. described it as extremely frightening. After that, the panic attacks reappeared and S. feltanxious and distressed again. She started to avoid going towork and asked for a long sick leave. She did not meet criteriafor full post-traumatic disorder, and the therapist decided notto add antidepressant medications, but to intensify psycho-

therapy.25

The CBT protocol was implemented again, butthis time S. did not respond readily and anxiety levels andsomatization were very high. Subsequently, her boyfriendreceived a promotion in a law rm and decided to ask her toget married. At this stage of the therapy she reported that her panic attacks were easy problems when compared to thedecision to get married. She felt insecure and still attracted toher colleague at work, and consequently the emotionaldistress was very intense. The therapist noted at this pointthat the patient was now seeking help for dealing withexistential issues, rather than simply overc oming panicdisorder. A more holistic, integrative approach 3 appeared tobe crucial at this point of the therapeutic process.

In the wake of the promising results o btained by thenarrative group intervention described above, 23 the therapistintroduced a set of narrative techniques for helping the patientto work on these moral and existential problems. S. wasinvited to review her life, with particular attention to thecharacteristics of previous partners and love affairs and todiscuss them during session. The therapist used metaphors andfound analogies between these various partners and similar characters in traditional fairytales (i.e., the prince charming,the ugly toad, and the evil ogre). At home, S. was assignedthe homework of writing a fairytale that re pr esented her life,using the fairytale narrative basic structure 24 and imagining its happy ending. No speci c instructions were added interms of time settings, number of characters, or length of themanuscript. The patient was left free to facilitate her creativity. In the next session the therapist examined thefairytale written by S., which was very short and simplistic.The therapist then underlined the narrative mistakes and themissing points: for instance, her character (the young princess)was not suf ciently characterized and was extremely passivethroughout the story. The imagined happy ending involvedher very rst boyfriend coming back and rescuing her from anunhappy marriage with the current one, but no details wereprovided on this former boyfriend, the reasons why he wasback, or their future planning. The patient was thus asked towrite again the same fairytale, correcting the mistakes, adding details, and giving to the young princess a more active role inthe story.

In the subsequent session S. reported feeling much better.She said that she felt she was emotionally un-blocked for the

rst time after many months, and that she nally understoodthe value of her relationship with the current boyfriend.When examining the newly written fairytale, in fact, thehappy ending was completely changed and, this time, sheidenti ed her current boyfriend as her real prince charming. She imagined a realistic future with him, involving a baby, anew home in the countryside, and other positive outcomes. S.reported that the homework of writing a structured ction

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story really helped her to examine people and situations in anew light, with the right emotional distance, and with a wiser perspective. She understood she already had a valuable personand a brilliant future with him and decided to get marriedto him.

After this cognitive and emotional maturation S. decidedto go back to work, to stop irting with the colleague and to

engage in organizing her wedding. Her panic attacks gradually disappeared, with some more exposure homework that waseasily undertaken by the patient. She continued to create andwrite new fairytales for addressing ongoing problems in her daily life, such as nancial dif culties, and resolving work andfamily issues. S. reported that this narrative technique hadreally helped her, providing a valid, symbolic framework for interpreting reality. At a three-month follow-up visit, she wasstill in recovery and happily engaged with her boyfriend.

DISCUSSION AND THERAPEUTIC IMPLICATIONSThis case report illustrates the integration of narrative techni-ques, based on traditional fairytales, in the process of CBTpsychotherapy. These narrative techniques consisted of vari-ous elements:

(a) Re-formulation of the patient s dif culties and problems in a narrative way: The patient was guided to think about her problems using a story plot (beginning, development of the situation, and nal positive resolution) and using character s and metaphors traditionally endorsed by fairytales.24

(b) Creative writing of a new fairytale : The patient was cogni-tively engaged in building the plot and nding possiblepositive outcomes.

(c) Sharing and discussing the fairytale with the therapist, insession: The therapist underlined the narrative mistakesor the lacking parts of the story, where resistance or dif culties indirectly emerged.

(d) Correction and re-writing of the fairytale , or a new one, using suggestions and indications provided by the therapist.

The use of these narrative strategies, in a phase of CBTwhere this patient was not responding to treatment and wasnot able to engage in cognitive restructuring, yielded imme-diate bene ts and facilitated the abatement of resistances andemotional blocks. Throughout the process of the fairytalecreation, the patient was able to use a metaphorical languageand exercise her building of symbolism. In the process of writing her original fairytale, S. could work at creating metaphors rather than just interpreting them. The working approach was I would like to convey this characteristic or feeling, so what action/symbol could I employ in order to doso? rather than This event has occurred in the story: whatcould it mean, what could it stand for? As a result, thepatient was able to develop her own symbolic language.Further, the emotions were projected in a ctional, impos-sible setting, and this provided her the right distance fromproblems, connected with a more effective cognitive engage-ment in prob lem solving. This is in accordance with Whiteand Epston s13 observations that a more richly described

narrative enables the person to reposition his or her self inrelation to the problem.

This emotional distance is similar to the therapeuticprinciple of cognitive defusio n endorsed in Acceptance andCommitment therapy (ACT) 26 or in the Mindfulness-basedtherapeutic approach. 8 The emotional distance is also aspeci c psychotherapeutic ingredient of Wisdom Psycho-

therapy, a recently validated gro up psychotherapy for addressing embitterment disorders. 27 Recent psycho-therapeutic approaches thus suggest an important role for helping patients to achieve the right self-distance from their problems, allowing them to reach a new, wider perspectiveand a subjective self-maturation. The narrative techniquesused with this case report yielded bene ts in terms of anxiety symptoms and personal maturation, facilitating the self-healing process. 4 ,21 This narrative approach can help addresssome of the limitations of CBT: even though C BT is aneffective treatment for mood and anxiety disorders, 28 it may have limitations when dealing with existential or moral issues,as in our patient, probably because in CBT the role of con ictual emotions and motivations is often downplayedand de-emphasized. 3 ,29 ,30 According to Goncalves andStiles,31 narrative strategies could be extremely helpful inthese clinical situations because patients are provided with theopportunity to transform true stories of problems into storiesof adaptation and meaningfulness. Psychotherapy, from thisperspective, is not only about sy mptom reduction , but alsoabout meaning, transformation, 31 and self-healing. 4

In conclusion, we suggest that the integration of fairytalesinto psychotherapy has an important educational role andsigni cant implications for helping patients to address their emotional distress and increase their personal growth andmaturation. According to our clinical experience, fairytalescan easily support the work of psychot her apy, even improving the value of standard CBT protocols. 3 ,30 ,32 Further research,with a larger sample, controlled design, and speci cdiagnostic groups is needed in order to test and clarify therole of fairytales in the psychotherapeutic and clinicalprocess.

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